IMMUNIZATION o Live attenuated microorganism

The process of inducing immunity against a specific Measles, mumps, rubella,

disease varicella, rotavirus, and live
Passive through administration of antibody- attenuated influenza vaccines
containing preparations o Toxoids
Active by administering a vaccine or toxoid to Modified bacterial toxin made
stimulate the immune system to produce a non-toxic but still able to induce
prolonged humoral and/or cellular immune an active immune response
response Tetanus and diphtheria

Passive Active Most B-lymphocyte response re quire the assistance of

Administration of Injection of an antigen CD4 helper T lymphocytes. These T-lymphocyte-
preformed Ab dependent responses tend to induce high levels of
Can be induced naturally Protection produced by functional antibody with high avidity, mature over time
through transplacental the persons own from primarily an IgM response to a long-term persistent
transfer of Ab during immune system IgG response and induce immunologic memory that
gestation leads to enhanced responses upon boosting.
Protection may persist Usually permanent T-lymphocyte-dependent vaccines
for months to as long as o Include protein moieties
a year after birth o Induce good immune responses even in
young infants
T-lymphocyte-independent vaccines
PASSIVE IMMUNIZATION
o Polysaccharide antigens induce B-
Major indication - to provide protection to:
lymphocyte responses in the absence
Immunodeficient children with B-
of T-lymphocyte help
lymphocyte defects who have difficulties
o Associated with poor immunity, and
making Ab
absence of an enhanced or booster
Persons exposed to infectious diseases or
response on repeat exposure to the
at imminent risk of exposure where there is not
antigen
adequate time to develop an active immune
o To overcome this, polysaccharides
response to a vaccine
have been conjugated, or covalently
Persons with an infectious disease as part of
linked, to protein carriers, converting
specific therapy for that disease
the vaccine to a T-lymphocyte-
dependent vaccine
ACTIVE IMMUNIZATION
Live Attenuated Vaccines
VACCINES
Tend to induce long-term responses
Defined as whole or parts of microorganisms
They replicate, often similarly to natural
administered to prevent an infectious disease
infections, until an immune response shuts
Can induce immunity through stimulation of
down reproduction
antibody formation, cellular immunity, or both
Mostly administered as single-dose schedules
Protection is thought to be mediated primarily
Repeat dose, like MMR, is to induce an initial
by B-lymphocytes, which produce antibody
immune response in persons who failed to
Can consist of:
respond to the first dose
o Whole inactivated microorganisms
IPV, Hepatitis A
Inactivated Vaccines
o Parts of microorganism
Tend to require multiple doses to induce an
Acellular pertussis, HPV,
adequate immune response
Hepatitis B
More likely to need boosters to maintain
o Polysaccharide capsules
immunity
Pneumococcal and
Some inactivated vaccines, however, appear
meningococcal polysaccharide
to induce long-term immunity, perhaps life-long,
vaccines
after a primary series
o Polysaccharide capsules conjugated to
o e.g. Hep B vaccine, IPV
protein carrier
Hib, pneumococcal, and
meningococcal conjugate
vaccines
ROUTE OF ADMINISTRATION
Injectable vaccines should be administered in
areas unlikely to cause local neural, vascular, or
tissue injury.
o Upper, outer quadrant of the buttocks
should not be used because the gluteal
region consists mostly of fat in young
children and because of potential injury
to the sciatic nerve
Intramuscular (IM) injections for infants and
young children
o Anterolateral thigh muscle
preferred because of its muscle
mass relative to other sites
o Needle length
58 in. for newborn infants
1 in. for infants 2-12 mo./o
1 to 1 14 in for older children
IM injections for adolescents and adults
o Deltoid muscle of the arm
o Needle length: 1 1 12 in
Subcutaneous inoculations also usually
should be given in the thigh of infants and the
deltoid area of older children
Intradermal vaccines generally should be
administered on the volar aspect of the forearm
Most inactivated vaccines, including DTaP, Hep
A, Hep B, Hib, inactivated influenza vaccine,
PCV13, MCV4, and Tdap, are administered
intramuscularly (IM).
Commonly used live attenuated vaccines, MMR
and varicella, should be dispensed
subcutaneously (SC)
IPV and PPS23 (pneumococcal polysaccharide
vaccine) can be given IM or SC
RV vaccine and OPV are the only US-licensed
vaccines for children that are administered by
the oral route
Managing Injection Pain
Truthful & empathetic preparation for injections
is beneficial, using the words that are
explanatory without evoking anxiety
pressure, squeezing and poking rather
than pain, hurt and shot
Parents and medical care providers should not
tell children that it wont hurt because this type
of statement has been show to ineffective in
reducing pain at the time of injection
Physical Techniques for Minimizing Injection
Pain
Breastfeeding
Children should be held on the lap of a
parent or other caregiver
Older children may be more comfortable
sitting on the examination table edge &
hugging their parent chest to chest
A rapid plunge of the needle through the
skin without aspirating and rapid injection
may decrease discomfort
Rubbing or stroking the skin near the
injection site with moderate intensity before
and during vaccination also may reduce the
sensation of pain
Psychological Techniques for Minimizing
Injection Pain
Parent-led or physician-led age-
appropriate distraction can reduce
pain-related distress at the time of
injection
Pharmacologic Techniques for Minimizing
Injection Pain
Topically applied agents may reduce
the pain of injection
o Currently available topical
anesthetics require 30-60
minutes to provide adequate
anesthesia so planning ahead is
necessary
Simultaneous Administration of Multiple Vaccines
Most vaccines can be given simultaneously
without impairment of effectiveness or safety
Data indicate possible impaired immune
responses when 2 or more parenterally
administered live-virus vaccines are not given
simultaneously but rather within 28 days of each
other
VACCINE CONTRAINDICATIONS AND
PRECAUTIONS
Contraindication
o A condition in a patient that increases
the risk of a serious adverse reaction
and for whom this increased risk of an
adverse reaction outweighs the benefit
of the vaccine
 Precaution
o A condition in a recipient that might
increase the risk or seriousness of an
adverse reaction or complicate making
another diagnosis because of a
possible vaccine-related reaction
Established, generic contraindications are:
o moderate or severe illness
o a previous anaphylactic reaction to the
specific vaccine, and
o a severe hypersensitivity reaction, such
as anaphylaxis, to a vaccine constituent
The decision to defer immunization in a febrile
child should be based on the physicians
assessment of the severity of the illness rather
than the degree of fever
o Children with minor illness and low-
grade fever generally should be
vaccinated, especially if a child is
unlikely to return promptly for the
deferred immunization
Administration of live virus vaccines such as
MMRV generally is contraindicated in patients
with altered immunity
o Morbidity & mortality rates of measles
and lack of complication from
vaccination of children infected with HIV
have led to recommendations that
these children, unless significantly
immunocompromised, receive the
MMR vaccine
Because of a theoretical risk to the developing
fetus, administration of live virus vaccines in
most cases is not recommended for pregnant
women
MISCONCEPTIONS
Common conditions that should not delay vaccination
but often are considered mistakenly to be
contraindications include:
Diarrhea
Minor upper respiratory tract illnesses (including
otitis media) with or without fever
Mild to moderate local reactions to a previous
dose of vaccine
Exposure to an infectious disease
Current antimicrobial therapy
Being in the convalescent phase of an acute
illness
Allergy to duck meat or duck feathers
Allergy to an antibiotic (except anaphylactic
reaction to neomycin, gentamicin,
or streptomycin, if any of these are in the
vaccine to be administered)
History of non-anaphylactic allergy to egg
Personal or family history of seizures
Family history of sudden unexpected death
Family history of an adverse event following
immunization
Breastfeeding or pregnancy in a household
contact
Lapsed Immunizations
A lapse in the immunization schedule does not
require reinitiating the entire series or addition of
doses to the series for any vaccine in the
recommended schedule
Subsequent immunizations should be given at
the next visit as if the usual interval had elapsed
o For RV vaccine, the doses to be
administered are age limited, so catch-
up may not be possible
Unknown or Uncertain Immunization Status
A person with unknown or uncertain
immunization status should be considered
disease-susceptible, and recommended
immunizations should be initiated without delay
on a schedule commensurate with the persons
current age
Serologic testing is an alternative to vaccination
for certain antigens (e.g. measles, rubella,
hepatitis A, and tetanus)
No evidence suggests that administration of
vaccines to already immune recipients is
harmful
Interchangeability of Vaccine Products
When possible, effort should be made to
complete a series with vaccine made by the
same manufacturer
Although data documenting the effects of
interchangeability are limited, most experts
have considered vaccines interchangeable
when administered according to their
recommended indications
Licensed vaccines that may be used
interchangeably during a vaccine series
include:
o Diphtheria & tetanus toxoid
vaccines
o Hepatitis A vaccines
o Hepatitis B vaccines
o Rabies vaccines
o RV vaccines
as long as recommendations
concerning conversion from a 2-
dose regimen to a 3-dose
regimen are followed
o Hib conjugate vaccines
as long as recommendations for a
total of 3 doses in the first year of
life are followed
The National Immunization Program (NIP)
Previously known as the Expanded Program on
Immunization (EPI)
Consists of the following antigens:
o BCG vaccine, single dose given at birth
o Monovalent Hepatitis B vaccine given at
birth
o DPT-Hib-Hep B vaccine, 3 doses given
at 6-10-14 weeks of age
o Oral Polio vaccine (OPV), 3 doses given
at 6-10-14 weeks of age, a single dose
of Inactivated Polio vaccine (IPV) is
given with the 3rd dose of OPV at 14
weeks
o Pneumococcal conjugate vaccine
(PCV), 3 doses given at 6-10-14 weeks
of age
o Rotavirus vaccine given at a minimum
age of 6 weeks with a minimum interval
of 4 weeks between doses. The last
dose should be administered not later
than 32 weeks of age.
o Measles-containing vaccine (either
monovalent measles vaccine or MMR)
given at 9 months of age
o Measles-Mumps-Rubella (MMR)
vaccine given at 12 months of age
A school based immunization program to
provide catch-up doses for school children and
adolescents has been established
o Measles-Rubella (MR) and Tetanus-
Diphtheria (Td) vaccines are
administered to Grade 1 and Grade 7
students enrolled in public schools
o Human Papillomavirus (HPV) shall be
given to female children 9-10 years old
at health facilities in priority provinces
Quadrivalent HPV 2 doses are
given at 0, 6 months
Other recommended vaccines not part of the NIP
o Japanese Encephalitis vaccine
o Influenza vaccine (Trivalent/Quadrivalent)
o Hepatitis A vaccine
Interim recommendation for use
o Dengue tetravalent vaccine
BACILLE CALMETE-GURIN (BCG) VACCINE Special Indications
Live attenuated strain derived from o For pre-term infants
Mycobacterium bovis Born to HBsAg (-) mothers &
Used primarily in young infants in an attempt to medically stable give 1 dose
st

prevent disseminated and other life-threatening at 30 days chronological age

manifestations of M. tuberculosis disease regardless of weight and this can
o However, does not prevent infection with be counted as part of the 3-dose
M. tuberculosis primary series
Given on the right upper deltoid, intradermally, at Another dose of HBV is needed
birth or at earliest possible age after birth, for those < 2 kg whose 1 dose
st

preferably within the first 2 months was received at birth

Dose: o For term infants
o 0.05 mL children less than 12 months Born to HBsAg (+) mothers -
o 0.1 mL children more than 12 months give HBV and HBIg (0.5 mL)
Contraindications: within 12 hours of life. HBIg
o Burns, skin infections, certain primary or should be administered not later
secondary immunodeficiencies (including than 7 days of age, if not
HIV infection), persons receiving immediately available
immunosuppressive medications o For infants born to mothers w/
(including high-dose corticosteroids) unknown HBsAg status
Adverse Reactions BW 2 kg
o Uncommon (1-2%) Administer HBV within
Subcutaneous abscess 12 hours of birth and
Regional (axillary) determine mothers
lymphadenopathy HBsAg ASAP. If HBsAg
o Rare (0.1 to 1 case per million) (+), administer HBIg not
Osteitis affecting the epiphysis of later than 7 days of age
long bones BW < 2 kg
Disseminated fatal infection Administer HBIg in
addition to HBV within
Usual Accelerated 12 hours of life
Reactions Reactions Contraindications
Induration 2-4 weeks 2-3 days o History of anaphylaxis to a previous dose
Pustule formation 5-7 weeks 5-7 days of vaccine
Scar formation 2-3 months 2-3 weeks Adverse Reactions
o Soreness at injection site
o Possible association with GBS following
HEPATITIS B VACCINE
first dose of plasma-derived vaccine; no
HBV infection is a leading cause of acute hepatitis
evidence of association with recombinant
Incidence is especially high in many Asian and
vaccine
African countries
Given intramuscularly, in the anterolateral thigh or
DIPHTHERIA AND TETANUS TOXOID AND PERTUSSIS
deltoid area (depending on the age and size of the
(DTP) VACCINE
recipient)
Diphtheria and Tetanus component are toxoids
o Only single-antigen hepatitis B vaccine
while Pertussis component can either be whole-
can be used for doses given to infants
cell (DTP) or acellular (DTaP)
between birth and 6 weeks of age
o Incidence of local and systemic reactions
o Single-antigen or combination vaccine
are more associated with whole-cell
may be used to complete the series; four
pertussis vaccine
doses of vaccine may be administered if a
Given intramuscularly
birth dose is given and a combination
vaccine is used to complete the series Given at a minimum age of 6 weeks with a
Schedule: Birth-6-10-14 weeks (minimum interval minimum interval of 4 weeks
o Recommended interval between 3rd and
of 4 weeks)
Dose: 0.5 mL 4th dose is 6 months but a minimum of 4
months is valid
o 5th dose may not be given if the 4th dose
was administered at age 4 years or older
 Contraindications
o Immediate anaphylactic reaction
subsequent immunization with any of the
three components should be avoided
o Encephalopathy
Defined as a severe, acute, CNS
disorder unexplained by another
cause and may be manifested by
major alterations in
consciousness or by generalized
or focal seizures that persist for
more than a few hours without
recovery within 24 hours
Occurring within 7 days after
administration of a previous dose
of DTP/DTaP/Tdap not
attributable to another
identifiable cause
Should not receive additional
doses of a vaccine that contains
pertussis
Adverse Reactions
o Whole-cell pertussis vaccine
Local & febrile reactions more
common; develop within the first
24 hours and brief in duration
More serious uncommon,
usually occurs within the first 48
hours of receiving vaccination,
resolves spontaneously without
sequelae:
Prolonged crying for 3
hours or longer
occurring
Temperature of 40.5OC
or greater
Hypotonic-
hyporesponsive episode
described as collapse or
shock-like state
Seizure within 3 days of
vaccination brief, self-
limited, and generalized
and occur in association
with fever
o Acellular pertussis vaccine
Local & febrile reactions as well
as more serious reactions rarely
occur
HAEMOPHILUS INFLUENZAE TYPE B (Hib) VACCINE
Before the introduction of routine infant and
childhood vaccination against Hib, this pathogen
was the major cause of invasive bacterial
infections in young children (meningitis and
epiglottitis)
Given intramuscularly
Given as a 3-dose primary series with a minimum
age of 6 weeks and a minimum interval of 4 weeks;
booster dose is given between 12-15 months of
age with an interval of 6 months from the 3rd dose
Adverse Reactions
o Hib vaccines are well-tolerated
o Local reactions occur in approximately
25% of recipients but typically are mild
and last less than 24 hours
POLIOMYELITIS VACCINE
Two forms:
o OPV (Sabin strain)
Elimination of poliovirus infection
has been achieved primarily
through the use of OPV
Induced optimal intestinal
immunity, painless and
secondarily immunized some
contacts by fecal-oral spread of
the vaccine virus
o IPV (Salk strain)
To eliminate the risk for vaccine-
associated paralytic polio
Since 2000, outbreaks of paralytic poliomyelitis
caused by neurovirulent polioviruses that are
derived from Sabin OPV vaccine strain have
occurred among underimmunized children living in
certain economically deprived regions
o Low immunization rates permitted these
vaccine-derived polioviruses (VDPV) to
circulate for long periods of time and by
continuous mutation, acquire biologic
properties that are indistinguishable from
naturally occurring wild polioviruses
OPV given per orem; IPV given intramuscularly
Contraindications
o History of anaphylactic reaction after
receiving a previous dose of IPV or an
anaphylactic reaction to one of the
antibiotics in the vaccine preparation (i.e.
streptomycin, polymyxin B or neomycin)
o Pregnant women
Adverse Reactions
o OPV can cause vaccine-associated
paralytic polio
PNEUMOCOCCAL VACCINE
S. pneumoniae is the most common cause of otitis
media, occult bacteremia, and bacterial
pneumonia requiring hospitalization
Given intramuscularly, for 3 doses, at a minimum
age of 6 weeks with an interval of at least 4 weeks
between doses plus a booster dose given 6
months after the 3rd dose
Adverse Reactions
o PCV appears to be safe
o Most commonly reported reactions are
local reactions at the injection site
Contraindications
o In persons who have had a severe
reaction, such as anaphylaxis or a
localized, severe hypersensitivity
response, revaccination should be
avoided
ROTAVIRUS VACCINE
RV is a major cause of AGE
Given per orem
o Monovalent human RV vaccine (RV1) is
given as a 2-dose series
Provided as a lyophilized powder
that is reconstituted with a
supplied diluent
o Pentavalent human bovine RV vaccine
(RV5) is given as a 3-dose series
Provided in a squeezable plastic
dosing tube with a twist-off cap
Given at a minimum age of 6 weeks with a
minimum interval of 4 weeks between doses; the
last dose should be administered not later than 32
weeks of age
Contraindications
o Severe hypersensitivity to any component
of the vaccine
RV1 oral applicator contains latex
o Severe combined immunodeficiency
(SCID)
o History of intussusception
o RV vaccine should not be administered to
infants with acute, moderate to severe
gastroenteritis until the condition
improves
Adverse Reactions
o Intussusception
Associated with a tetravalent
rhesus-based RV vaccine;
withdrawn from the market
Data from phase III efficacy trials
of RV5 did not suggest an
increased risk for development of
intussusception relative to
placebo
MEASLES VACCINE
Given subcutaneously, at age 9 months but may
be given as early as 6 months of age in cases of
outbreaks as declared by public health authorities
Adverse Reactions
o Immunization produces a mild or
inapparent, non-communicable infection
o Vaccine-associated symptoms (fever
higher than 39.4OC occurring 5-10 days
after immunization or transient rash)
develop in 5-18% of recipients
o Thrombocytopenia
Usually not clinically apparent
but thrombocytopenic purpura
occurring after vaccination has
been reported
o CNS disease (encephalitis or
encephalopathy) reported at a rate of
less than 1 case/1 million doses of
vaccine administered
o SSPE risk is extremely low (0.7 SSPE
cases per million vaccine doses)
o To date, no convincing evidence
establishes that any vaccine causes
autism or autism spectrum disorder
Contraindications
o Immunocompromised patients
(malignancy, primary or secondary
immunodeficiency states) EXCEPT
asymptomatic HIV-infected patients
After cessation of chemotherapy,
patients should not receive
measles vaccine for at least 3
months
o Persons who have received systemic
corticosteroids in doses of 2mkday or 20
mg daily or on alternate days for an
interval of 14 days or longer should avoid
receiving MMR vaccine for at least 1
month after cessation of CS therapy
MEASLES-MUMPS-RUBELLA (MMR) VACCINE
Given subcutaneously, for 2 doses, at a minimum
age of 12 months with a minimum interval of at
least 4 weeks
o 2nd dose is usually given from 4-6 years of
age but may be given earlier
Adverse Reactions
o Parotitis and fever mumps component
o Fever, lymphadenopathy, or rash rubella
component
Contraindications
o Pregnancy
o Sever febrile illness
o Known history of anaphylactic reaction to
rubella vaccine, gelatin or neomycin
o Immunodeficiency states
VARICELLA VACCINE
Given subcutaneously, for 2 doses, at a minimum
age of 12 months (12-15 mos) and 2 dose given
nd
at 4-6 years of age
o 2-dose regimen is recommended to
prevent breakthrough varicella
(chickenpox occurring in a previously
vaccinated person) due to waning
antibody titers
Adverse Reactions
o Local reactions
o Varicella-like rash at site of injection
Occur within 2 weeks, usually
maculopapular rather than
vesicular
Contraindications similar to MMR vaccine
MEASLES-MUMPS-RUBELLA-VARICELLA (MMRV)
VACCINE
Can be given as an alternative to separately
administered MMR and varicella vaccine
INFLUENZA VACCINE
2 forms
o Trivalent vaccine given either
intramuscularly or subcutaneously
o Quadrivalent vaccine given
intramuscularly
Dose:
o 6 months to 35 months 0.25 mL
o 36 months to 18 years 0.5 mL
Given at a minimum age of 6 months
o Children 6 months to 8 years receiving
influenza vaccine for the first time 2
doses, 4 weeks apart
o Children 9 to 18 years 1 dose annually
Schedule: Annual vaccination should begin in
February but may be given throughout the year
Contraindications
o Trivalent inactivated influenza vaccine
(TIV)
Infants younger than 6 months
Children who have a moderate to
severe febrile illness
o Live attenuated influenza vaccine (LAIV)
Pregnancy
Children younger than 2 years
Moderate to severe febrile illness
Receiving aspirin or salicylates
Immunosuppressed states
Chronic, underlying medical
condition (metabolic disorders,
DM, pulmonary, cardiac, renal
disorders or
hemoglobinopathies)
Children aged 2-4 years old with
a history of recurrent wheezing or
a medically attended wheezing
episode in the previous 12
months
Children taking influenza antiviral
medications should not receive
LAIV until 48 hours after stopping
therapy
HEPATITIS A VACCINE
Given intramuscularly, as a 2-dose series, at a
minimum age of 12 months where the 2nd dose is
given at least 6 months from the 1st dose
HUMAN PAPILLOMAVIRUS VACCINE (HPV)
Genital HPV infection is thought to be the most
common sexually transmitted viral infection
Infection with HPV causes virtually all cases of
cervical cancer
Given intramuscularly, as a 3-dose series, with a
minimum age of 9 years
2 types and schedule of doses
o Bivalent HPV (HPV2) given at 0, 1 and 6
months
o Quadrivalent HPV (HPV4) given at 0, 2 and
6 months
The only HPV vaccine
recommended for routine
immunization of males at 11 or 12
years of age
Minimum interval between the 1st and 2nd dose is
at least 1 month and the minimum interval between
the 2nd and 3rd dose is at least 3 months.
o 2-dose schedule is an option for girls 9 to
14 years of age for both HPV2 and HPV4,
doses given at least 6 months apart
SOURCES:
Chapter 172, Nelson Textbook of Pediatrics, 20th edition
Chapter 244, Feigin & Cherrys Textbook of Pediatric
Infectious Diseases, 7th edition
Red Book 30th edition, American Academy of Pediatrics
Preventive Pediatric Health Care Handbook 2016,
Philippine Pediatric Society
kmbm 2016

JAPANESE ENCEPHALITIS VIRUS VACCINE

JE virus is the most important cause of epidemic
arboviral encephalitis in Asia
o JE is endemic in the Philippines
Given subcutaneously
o Children 9 months to 17 years should
receive one primary dose followed by a
booster dose 12-24 months after the
primary dose
o Individuals 18 years and older should
receive a single dose only
Contraindications
o Previous severe allergic reaction after a
previous dose of JE-VC is a
contraindication to administration of
subsequent doses
Contains protamine sulfate
Adverse Reactions
o Local or mild systemic reactions